Southern Indiana Rehab Hospital (“SIRH”) its Medical Staff, employees, residents, fellows, students, contractors and volunteers follow the privacy practices described in this Notice of Privacy Practices (“Notice”). This Notice describes how SIRH may use and disclose your health information when you receive services and treatment at SIRH. SIRH participates in an organized health care arrangement with its Medical Staff and will share your health information with the arrangement’s participants to carry out treatment, payment or health care operations related to the organized health care arrangement. This Notice does not cover the privacy practices of your physician when you see him or her in a private office setting. SIRH is committed to protecting your health information in a confidential manner.

LEGAL RESPONSIBILITIES OF SIRH

SIRH is required by law to protect the privacy of your protected health information (“PHI”) – health information about you and that can identify you – and to give you notice of our legal duties and privacy practices concerning your protected health information.

SIRH must abide by the terms of this Notice;

SIRH must notify you if we are unable to agree to a restriction that you request about the use and disclosure of your protected health information;

SIRH must accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

SIRH will not use or disclose your health information without your authorization, except as described in this Notice.

SIRH may change its Notice at any time and make the new provisions effective for all protected health information SIRH maintains. Upon your request, SIRH will provide you with information about how to obtain a revised Notice of Privacy Practices by accessing our web site, http://www.sirh.org, by calling SIRH at (812) 941-8300 to request a revised copy be mailed to you, or by requesting one at the time of your next visit.

UNDERSTANDING YOUR MEDICAL RECORD

Each time you visit SIRH, a record of your visit is made. Typically, this record includes, but is not limited to, your demographic information, symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment, as well as payment information. This information, often referred to as your medical record, serves as a:

Basis for planning your care and treatment;

Means of communication among the health professionals who contribute to your care;

Legal document describing the care you received;

Means by which you or your insurance provider can verify that services billed were actually provided;

Tool in educating heath professionals;

Source of data for medical research;

Source of information for public health officials charged with improving the health of the nation;

Source of data for facility planning and marketing;

Tool SIRH uses to assess and continually work to improve SIRH care.

Understanding what is in your record and how your health information is used helps you to:

Treatment, Payment and Health Care Operations. SIRH will use or disclose your protected health information for treatment, to obtain payment for treatment, and for health care operations. The categories below describe the ways that SIRH may use and disclose health information. The examples given are not meant to be exhaustive, but describe common types of disclosures SIRH may make.

Examples of Uses and Disclosures for Treatment. SIRH will use and disclose your health information to:

Anyone involved in your treatment, including physicians, nurses, therapists, pharmacists, radiologists, discharge planners, dietitians, laboratory and others who need access to your health information in order to assist in your diagnosis and treatment.

Provide, coordinate, or manage your health care treatment, including the coordination or management of your care with a provider outside SIRH, such as a home health agency that is evaluating your need for home health services.

The physician who referred you to SIRH or who will provide follow-up care to you to assist with your continued care after you are discharged from SIRH.

Examples of Uses and Disclosures for Payment. SIRH will use and disclose your health information to:

SIRH may use or disclose your health information in the following situations without your authorization. These situations include:

Business Associates of SIRH: Some services are provided through contracts with business associates. Examples include physician services in radiology, certain laboratory tests, and the dictation service SIRH uses. When these services are contracted, SIRH may disclose your health information to our business associate so that they can perform the job SIRH has asked them to do and bill you or your insurance carrier for services rendered. To protect your health information, however, SIRH requires the business associate to appropriately safeguard your information.

Research: SIRH may disclose limited information for medical research under certain circumstances.

Marketing: SIRH may use or disclose health information to contact you with information about treatment, services, products or health care providers that may be of interest to you.

Fundraising: SIRH may use your demographic information and dates of health care provided in an effort to raise money to support the educational and medical research mission of SIRH. SIRH may disclose the information to any of the foundations of its owner facilities so that the foundations may contact you about fund raising efforts on behalf of SIRH. If you do not want to be contacted for fundraising purposes, please contact SIRH at (812) 941-8300.

Funeral Directors, Coroners and Medical Examiners: SIRH may disclose health information to a coroner, medical examiner or funeral directors consistent with applicable law to carry out their duties.

Organ procurement organizations: Consistent with applicable law, SIRH may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Public Health: As required by law, SIRH may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. These activities include but are not limited to reporting births, deaths, disease, injury, child abuse or neglect and domestic violence.

Inmates: If you are an inmate of a correctional institution, or under the custody of a law enforcement official, SIRH may disclose your health information to the institution or law enforcement official as may be necessary for your health and the health and safety of other individuals.

Legal Proceedings: If you are involved in a lawsuit or dispute, SIRH may disclose your health information in response to a court or administrative order. SIRH also may disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: SIRH may disclose health information for law enforcement purposes as required by law or in response to a valid court order, subpoena, warrant, summons or similar process. This includes providing information about someone who is suspected to be a victim of a crime, abuse, neglect or domestic violence; to provide information about a crime that occurs at SIRH or to identify or locate a suspect, fugitive, material witness or missing person.

Health Oversight Activities: SIRH may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights.

Military Activity and National Security: SIRH may release your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law, including providing protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Unless you notify SIRH in writing that you object, SIRH may use or disclose PHI about you in the following circumstances:

SIRH will include your name, location at SIRH, general condition (e.g. good, fair, serious, or critical) if available, and religious affiliation in the facility directory. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

SIRH may disclose to a member of your family, a relative, a close friend or any other person you identify as your emergency contacts, your health information that relates to that person’s involvement in your care or payment related to your care. SIRH may use or disclose your health information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, about your location, general condition or death.

SIRH may use or disclose your health information to a public or private entity (such as the American Red Cross) assisting in disaster relief efforts so that your family can be notified about your condition, status and location.

SIRH may use or disclose your health information for the above activities when you are unable to agree or object to the use or disclosure because of your incapacity or an emergency treatment circumstance if such disclosure is consistent with a prior expressed preference and if we determine such disclosure is in your best interest. When it becomes practical to do so, we must provide you with an opportunity to object to the uses or disclosures of your health information as described above.

To object to these uses or disclosures, please contact SIRH
at (812) 941-8300.

Except as described above, SIRH will not use or disclose your protected health information unless you give written authorization to SIRH to do so. You may revoke your permission, which will be effective only after the date of your written authorization. If you revoke your authorization in writing, SIRH will not disclose health information about you after SIRH receives your revocation except for disclosures that were being processed prior to receipt of your request.

Below is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

Right of Access. You have the right to access, inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A ” record set” contains medical and billing records and any other records that are used by SIRH or its Medical Staff to make decisions about you. Your request must be in writing. SIRH must act on your request no later than 30 days after receipt of the request. If the protected health information is not maintained or accessible on-site, SIRH must take action no later than 60 days from receipt of your request. SIRH also may extend the time for such actions by no more than 30 days. SIRH must provide you with a written statement of the reasons for the delay and the date by which it will complete your request. SIRH may charge you related fees if allowed by applicable law. Under federal law, however, you may not access, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. SIRH may deny your request to inspect and copy in certain circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by SIRH will review your request and the denial. The person conducting the review will not be the person who denied your request. SIRH will comply with the outcome of the review. Please contact the SIRH Health Information Management (HIM) Department at (812) 941-6269 about access to your medical record.

Right to request restrictions. You have the right to request restrictions on certain uses or disclosures of your protected health information for the purposes of treatment, payment or health care operations. You also may request limits on the health information SIRH discloses about you to family members, friends or other individuals identified by you who may be involved in your care or for notification purposes as described in this Notice. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. SIRH is not required to agree to your request. If SIRH agrees, SIRH will comply with the requested restriction unless it is needed to provide emergency treatment. To find out how to request a restriction, call the SIRH HIM Department at (812) 941-6269.

Confidential Communications. You have the right to request to receive confidential communications of protected health information from SIRH by alternative means or at an alternative location. For example, you can ask that SIRH only contact you at work or by mail. Your request must be in writing. SIRH will accommodate reasonable requests. SIRH also may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. SIRH will not request an explanation from you as to the basis for the request. To find out how to request confidential communications, please call the SIRH HIM Department at (812) 941-6269.

Right to Amend. If you believe that the health information SIRH has about you is incorrect or incomplete, you may request that the information be amended. You have the right to request an amendment for as long as the information is kept by or for the SIRH facility that maintains the record. Your request must be in writing and must explain the reason for the requested amendment. SIRH must act on your request for an amendment no later than 60 days after receipt of such a request. In certain cases, SIRH may deny your request for an amendment. If SIRH denies your request for amendment, you have the right to file a statement of disagreement with SIRH and SIRH may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. To find out how to request an amendment, please call the SIRH HIM Department at (812) 941-6269.

Right to an Accounting of Disclosures. You have the right to request a list of the disclosures SIRH made of your health information for purposes other than treatment, payment or health care operations as described in this Notice. It excludes disclosures SIRH may have made to you, requested by you or that you authorized, as well as for a facility directory, to family members or friends involved in your care, or for notification purposes. Your request must be in writing. SIRH must act on your request for an accounting, no later than 60 days after receipt of such a request. You have the right to receive specific information regarding these disclosures made up to six (6) years before your request (not including disclosures made before April 14, 2003). You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. If you request a list of disclosures more than once in 12 months, SIRH may charge you a reasonable fee. To find out how to request an accounting of disclosures, please call the SIRH HIM Department at (812) 941-6269.

Right to a Copy of this Notice. You have the right to receive, upon request, a written copy of this Notice. You may obtain a copy of this Notice at the SIRH web site, http://www.sirh.org. To obtain a paper copy of this Notice, visit the Admissions Department at SIRH, or call the SIRH Admissions Office at (812) 941-6122.

Call the SIRH Privacy Officer at (812) 941-6111 to get more information about your privacy rights as described in this Notice.

TO REPORT A PROBLEM

If you believe your privacy rights have been violated, you may file a complaint with the SIRH Privacy Officer and with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the Privacy Officer, send correspondence to:

Southern Indiana Rehab Hospital (“SIRH”) its Medical Staff, employees, residents, fellows, students, contractors and volunteers follow the privacy practices described in this Notice of Privacy Practices (“Notice”). This Notice describes how SIRH may use and disclose your health information when you receive services and treatment at SIRH. SIRH participates in an organized health care arrangement with its Medical Staff and will share your health information with the arrangement’s participants to carry out treatment, payment or health care operations related to the organized health care arrangement. This Notice does not cover the privacy practices of your physician when you see him or her in a private office setting. SIRH is committed to protecting your health information in a confidential manner.

LEGAL RESPONSIBILITIES OF SIRH

SIRH is required by law to protect the privacy of your protected health information (“PHI”) – health information about you and that can identify you – and to give you notice of our legal duties and privacy practices concerning your protected health information.

SIRH must abide by the terms of this Notice;

SIRH must notify you if we are unable to agree to a restriction that you request about the use and disclosure of your protected health information;

SIRH must accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

SIRH will not use or disclose your health information without your authorization, except as described in this Notice.

SIRH may change its Notice at any time and make the new provisions effective for all protected health information SIRH maintains. Upon your request, SIRH will provide you with information about how to obtain a revised Notice of Privacy Practices by accessing our web site, http://www.sirh.org, by calling SIRH at (812) 941-8300 to request a revised copy be mailed to you, or by requesting one at the time of your next visit.

UNDERSTANDING YOUR MEDICAL RECORD

Each time you visit SIRH, a record of your visit is made. Typically, this record includes, but is not limited to, your demographic information, symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment, as well as payment information. This information, often referred to as your medical record, serves as a:

Basis for planning your care and treatment;

Means of communication among the health professionals who contribute to your care;

Legal document describing the care you received;

Means by which you or your insurance provider can verify that services billed were actually provided;

Tool in educating heath professionals;

Source of data for medical research;

Source of information for public health officials charged with improving the health of the nation;

Source of data for facility planning and marketing;

Tool SIRH uses to assess and continually work to improve SIRH care.

Understanding what is in your record and how your health information is used helps you to:

Treatment, Payment and Health Care Operations. SIRH will use or disclose your protected health information for treatment, to obtain payment for treatment, and for health care operations. The categories below describe the ways that SIRH may use and disclose health information. The examples given are not meant to be exhaustive, but describe common types of disclosures SIRH may make.

Examples of Uses and Disclosures for Treatment. SIRH will use and disclose your health information to:

Anyone involved in your treatment, including physicians, nurses, therapists, pharmacists, radiologists, discharge planners, dietitians, laboratory and others who need access to your health information in order to assist in your diagnosis and treatment.

Provide, coordinate, or manage your health care treatment, including the coordination or management of your care with a provider outside SIRH, such as a home health agency that is evaluating your need for home health services.

The physician who referred you to SIRH or who will provide follow-up care to you to assist with your continued care after you are discharged from SIRH.

Examples of Uses and Disclosures for Payment. SIRH will use and disclose your health information to:

SIRH may use or disclose your health information in the following situations without your authorization. These situations include:

Business Associates of SIRH: Some services are provided through contracts with business associates. Examples include physician services in radiology, certain laboratory tests, and the dictation service SIRH uses. When these services are contracted, SIRH may disclose your health information to our business associate so that they can perform the job SIRH has asked them to do and bill you or your insurance carrier for services rendered. To protect your health information, however, SIRH requires the business associate to appropriately safeguard your information.

Research: SIRH may disclose limited information for medical research under certain circumstances.

Marketing: SIRH may use or disclose health information to contact you with information about treatment, services, products or health care providers that may be of interest to you.

Fundraising: SIRH may use your demographic information and dates of health care provided in an effort to raise money to support the educational and medical research mission of SIRH. SIRH may disclose the information to any of the foundations of its owner facilities so that the foundations may contact you about fund raising efforts on behalf of SIRH. If you do not want to be contacted for fundraising purposes, please contact SIRH at (812) 941-8300.

Funeral Directors, Coroners and Medical Examiners: SIRH may disclose health information to a coroner, medical examiner or funeral directors consistent with applicable law to carry out their duties.

Organ procurement organizations: Consistent with applicable law, SIRH may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Public Health: As required by law, SIRH may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. These activities include but are not limited to reporting births, deaths, disease, injury, child abuse or neglect and domestic violence.

Inmates: If you are an inmate of a correctional institution, or under the custody of a law enforcement official, SIRH may disclose your health information to the institution or law enforcement official as may be necessary for your health and the health and safety of other individuals.

Legal Proceedings: If you are involved in a lawsuit or dispute, SIRH may disclose your health information in response to a court or administrative order. SIRH also may disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: SIRH may disclose health information for law enforcement purposes as required by law or in response to a valid court order, subpoena, warrant, summons or similar process. This includes providing information about someone who is suspected to be a victim of a crime, abuse, neglect or domestic violence; to provide information about a crime that occurs at SIRH or to identify or locate a suspect, fugitive, material witness or missing person.

Health Oversight Activities: SIRH may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights.

Military Activity and National Security: SIRH may release your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law, including providing protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Unless you notify SIRH in writing that you object, SIRH may use or disclose PHI about you in the following circumstances:

SIRH will include your name, location at SIRH, general condition (e.g. good, fair, serious, or critical) if available, and religious affiliation in the facility directory. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

SIRH may disclose to a member of your family, a relative, a close friend or any other person you identify as your emergency contacts, your health information that relates to that person’s involvement in your care or payment related to your care. SIRH may use or disclose your health information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, about your location, general condition or death.

SIRH may use or disclose your health information to a public or private entity (such as the American Red Cross) assisting in disaster relief efforts so that your family can be notified about your condition, status and location.

SIRH may use or disclose your health information for the above activities when you are unable to agree or object to the use or disclosure because of your incapacity or an emergency treatment circumstance if such disclosure is consistent with a prior expressed preference and if we determine such disclosure is in your best interest. When it becomes practical to do so, we must provide you with an opportunity to object to the uses or disclosures of your health information as described above.

To object to these uses or disclosures, please contact SIRH
at (812) 941-8300.

Except as described above, SIRH will not use or disclose your protected health information unless you give written authorization to SIRH to do so. You may revoke your permission, which will be effective only after the date of your written authorization. If you revoke your authorization in writing, SIRH will not disclose health information about you after SIRH receives your revocation except for disclosures that were being processed prior to receipt of your request.

Below is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

Right of Access. You have the right to access, inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A ” record set” contains medical and billing records and any other records that are used by SIRH or its Medical Staff to make decisions about you. Your request must be in writing. SIRH must act on your request no later than 30 days after receipt of the request. If the protected health information is not maintained or accessible on-site, SIRH must take action no later than 60 days from receipt of your request. SIRH also may extend the time for such actions by no more than 30 days. SIRH must provide you with a written statement of the reasons for the delay and the date by which it will complete your request. SIRH may charge you related fees if allowed by applicable law. Under federal law, however, you may not access, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. SIRH may deny your request to inspect and copy in certain circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by SIRH will review your request and the denial. The person conducting the review will not be the person who denied your request. SIRH will comply with the outcome of the review. Please contact the SIRH Health Information Management (HIM) Department at (812) 941-6269 about access to your medical record.

Right to request restrictions. You have the right to request restrictions on certain uses or disclosures of your protected health information for the purposes of treatment, payment or health care operations. You also may request limits on the health information SIRH discloses about you to family members, friends or other individuals identified by you who may be involved in your care or for notification purposes as described in this Notice. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. SIRH is not required to agree to your request. If SIRH agrees, SIRH will comply with the requested restriction unless it is needed to provide emergency treatment. To find out how to request a restriction, call the SIRH HIM Department at (812) 941-6269.

Confidential Communications. You have the right to request to receive confidential communications of protected health information from SIRH by alternative means or at an alternative location. For example, you can ask that SIRH only contact you at work or by mail. Your request must be in writing. SIRH will accommodate reasonable requests. SIRH also may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. SIRH will not request an explanation from you as to the basis for the request. To find out how to request confidential communications, please call the SIRH HIM Department at (812) 941-6269.

Right to Amend. If you believe that the health information SIRH has about you is incorrect or incomplete, you may request that the information be amended. You have the right to request an amendment for as long as the information is kept by or for the SIRH facility that maintains the record. Your request must be in writing and must explain the reason for the requested amendment. SIRH must act on your request for an amendment no later than 60 days after receipt of such a request. In certain cases, SIRH may deny your request for an amendment. If SIRH denies your request for amendment, you have the right to file a statement of disagreement with SIRH and SIRH may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. To find out how to request an amendment, please call the SIRH HIM Department at (812) 941-6269.

Right to an Accounting of Disclosures. You have the right to request a list of the disclosures SIRH made of your health information for purposes other than treatment, payment or health care operations as described in this Notice. It excludes disclosures SIRH may have made to you, requested by you or that you authorized, as well as for a facility directory, to family members or friends involved in your care, or for notification purposes. Your request must be in writing. SIRH must act on your request for an accounting, no later than 60 days after receipt of such a request. You have the right to receive specific information regarding these disclosures made up to six (6) years before your request (not including disclosures made before April 14, 2003). You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. If you request a list of disclosures more than once in 12 months, SIRH may charge you a reasonable fee. To find out how to request an accounting of disclosures, please call the SIRH HIM Department at (812) 941-6269.

Right to a Copy of this Notice. You have the right to receive, upon request, a written copy of this Notice. You may obtain a copy of this Notice at the SIRH web site, http://www.sirh.org. To obtain a paper copy of this Notice, visit the Admissions Department at SIRH, or call the SIRH Admissions Office at (812) 941-6122.

Call the SIRH Privacy Officer at (812) 941-6111 to get more information about your privacy rights as described in this Notice.

TO REPORT A PROBLEM

If you believe your privacy rights have been violated, you may file a complaint with the SIRH Privacy Officer and with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the Privacy Officer, send correspondence to: